Medication Reconciliation ~~~ The Safety Net What is the Problem? What is the Solution? How do WE do this? medrecPills What is the Problem? 2 to 7 per 100 admissions is the incidence rate of Adverse Drug Events. (Kaushal & Bates) 1 out of 5 injuries or deaths from errors associated with Adverse Drug Events are preventable. (Pronovost) 50% of all hospital medication errors occur at the interfaces of care. (Rozich) 60% of patients will have at least 1 discrepancy in the admission medication history. (Cornish) What is the Solution? Medication Reconciliation Med Rec: 3-Step Process Collect an accurate medication history Compare this history to the physician orders at ALL transition points Admission Transfer Discharge Correct any discrepancies medrecII Med Rec Project: Assemble Beta Test Collaborative Team Senior Administrative Leadership Clinical Leadership Physician Leader that is also a Senior Administrative Leader or a respected ‘thought leader’ among the physician group Pharmacist Manager Pharmacy Technician Unit Nurse Manager Staff Nurse Human Resource Patients Meanwhile…….. Pharmacist Manager establishes a retrospective baseline Obtain a set of 30 closed patient records 3 day minimum stay Timeline 1 to 3 months back Use a random selection process Count errors due to unreconciled medications Tally errors and report data as a monthly number of errors per 100 admissions Med Rec in Place: Outcomes 70% reduction in errors and 15% reduction in Adverse Drug Events over a 7 month period with med rec intervention. (Whittington) 80% reduction of potential adverse drug events, within 3 months, in segmented population of surgical patients utilizing pharmacy technicians to initiate the reconciling process. (Michels) How Do WE Do This? Model for Improvement Plan Forms Process Do Beta Test Study Retrospective Analysis User Feedback Act Policy Implementation Plan Do Study ACT Beta Project Resources Collaborative Team Project Manager 8 to10 hrs/ week the first 6 weeks of the 6 month beta test 24 to 36 hrs/month for the remainder of the project Team Members 1 to 4 hrs/week for the first 6 weeks of the 6 month beta test, depending on role 4 to 12 hrs/month for the remainder of the project The Right Thing to Do ~~~Engagement Impacts all four business quadrants Financials Product/Service/Quality Customer Satisfaction Workload (eventually) j0321057 This is Hard Work …. What if We Called It Asking people to change what they have been doing. Improved Communication Providing Optimum Care Improved Medication Management It is The Right Thing to Do medrecTEAM Med Rec Team Will ~~~ Provide Vision Prioritize Focus Share Project Data Share Project Success Stories Sunset